[Quality assurance for the treatment of muscle-invasive and metastasized bladder carcinoma in Germany : An initiative of the Working Groups Urological Oncology (AUO) and Internal Oncology (AIO) in the German Cancer Society (DKG)]. / Qualitätssicherung zur Therapie des muskelinvasiven und metastasierten Harnblasenkarzinoms in Deutschland : Eine Initiative der Arbeitsgemeinschaften Urologische Onkologie (AUO) und Internistische Onkologie (AIO) in der Deutschen Krebsgesellschaft (DKG).

BACKGROUND: The S3-guideline on bladder cancer recommends radical cystectomy and cisplatin-based perioperative chemotherapy (POC) for muscle-invasive bladder cancer (MIBC). Recommendation for metastatic urothelial cancer (mUC) is cisplatin-based or immuno-oncological (IO) treatment in platinum-ineligible patients (pts) or as 2nd-line therapy. OBJECTIVES: Aim of the study was to obtain representative data on clinical routine treatment of MIBC and mUC in Germany. MATERIALS AND METHODS: A nationwide survey was performed to obtain data on stage-related patient volume in hospitals and office-based physicians. Based on these results, a representative sample of treatment data was collected retrospectively from pts with MIBC and mUC. RESULTS: Data from 956 pts (MIBC 576; mUC: 380) were collected. Of the MIBC pts, 49.8% received a systemic therapy (80.4% of them received cisplatin/gemcitabine) and 50.2% were treated with a cystectomy without POC. Significant factors for cystectomy without POC were higher age > 75 years (odds ratio [OR] 4.91, 95% confidence interval [CI] 3.01-8.11, p < 0.001) and platinum-ineligible pts (OR 2.15, 95% CI 1.30-3.59; p = 0.003). Treatment decision without interdisciplinary tumor board was also correlated with no POC (OR 2.43, 95% CI 1.65-3.61, p < 0.001). In mUC platinum-pretreated pts generally receive IO therapy (OR 12.07, 95% CI 6.94-21.82, p < 0.001). Other significant factors are positive PD-L1 status (OR 3.72, 95% CI 1.30-5.71, p < 0.001), higher age > 75 years (OR 2.83, 95% CI 1.43-5.73, p = 0.003) and platinum-ineligible pts (OR 2.57, 95% CI 1.30-5.71, p = 0.007). CONCLUSIONS: The "gold standard" cisplatin/gemcitabine is established in Germany if pts are treated with POC. Nonetheless half of the MIBC pts did not receive a POC, especially if the treatment decision is not discussed in a tumor board. In mUC IO therapy is established as 2nd-line therapy after a platinum-based treatment. Although the guideline recommendations are largely implemented, there is potential for optimization, especially in the establishment of interdisciplinary tumor boards.

Detection accuracy of soft tissue complications during remote cochlear implant follow-up.

PURPOSE: After cochlear implantation (CI), long-term follow-up is obligatory. Remote-care options which provide a standard of care comparable to in-person consultations, could be an attractive addition to a cochlear implant centre's portfolio. The aim of this study was to evaluate the accuracy of photographs of the skin covering the implant to reliably detect skin irritations or soft tissue complications. METHODS: During routine follow-up consultations, 109 CI patients were examined in person and asked to take a photograph of the skin covering the implant using their smartphones. Photographs were digitally and remotely evaluated by two CI physicians who were blinded to the findings during the in-person examination. RESULTS: In nine cases, skin abnormalities were detected by the CI physician upon in-person examination, seven of which required immediate treatment. Both digital evaluators reliably detected all treatment-requiring conditions. Overall, more skin irritations were suspected digitally compared to in-person examination. Without additional information from the patients' medical record, sensitivity was 100% and specificity was 63%; with additional information provided, sensitivity was 100%, and specificity increased to 65.3%. CONCLUSION: Digital photographic assessment of the skin covering the implant is a highly sensitive method to detect skin irritations and could reduce the number of necessary in-person consultations.

Magnet dislocation following magnetic resonance imaging in cochlear implant users: Diagnostic pathways and managment.

OBJECTIVES: Although modern cochlear implants (CIs) are approved for magnetic resonance imaging (MRIs) adverse events still occur with unacceptable frequency. Methods: In this retrospective study, magnet displacement due to MRIs was analysed. Relevant factors e.g. symptoms during MRI, diagnostics, surgical intervention following the diagnosis and possible subsequent damage were assessed. RESULTS: 16 patients were enclosed. All patients complained about pain while the scan was conducted. Computed tomography (CT) scans of the temporal bone or X-rays of the skull were performed to confirm diagnosis. Artefacts on CT scans delayed immediate diagnosis in some cases. DISCUSSION: Despite various studies demonstrating the range of adverse events related to CIs following MRI, little information is available on diagnosis and radiologic recognition of magnet dislocation. In patients complaining about pain following an MRI scan an X-ray of the head should be performed immediately. Most adverse events occur in radiological centres without expertise in cochlear implants. CONCLUSION: Comprehensive training of patients, surgeons and radiologists is the most efficient tool to prevent damage to the CI and the patient. X-ray of the skull is suggested to be used as the method of choice in imaging.

[Transoral resection of supraglottic laryngeal tumors with the Flex Robotic System]. / Transorale Resektion von supraglottischen Larynxkarzinomen mit dem Flex Robotic System.

The Flex Robotic System (Medrobotics, Raynham, MA, USA) allows flexible transoral endoscopic resection of head and neck tumors. The current article presents functional and first oncologic experiences with flexible transoral robot-assisted surgery for resection of supraglottic laryngeal tumors. From July 2014 to February 2020, supraglottic cancers in 32 patients (T1 = 11, T2 = 20, T3 = 1) were resected using the Flex Robotic System in the authors' clinic. Within a prospective clinical study, the feasibility, complications, and oncologic results were assessed. Tumors could be exposed, visualized, and successfully resected in all patients. In difficult-to-reach anatomic regions such as the aryepiglottic fold or petiole, the system provided a very good surgical overview. No serious adverse events occurred. Overall survival and local tumor control after 2 years were 88 and 94%, respectively. In conclusion, supraglottic tumors in difficult-to-reach areas have been successfully resected using the Flex Robotic System, with excellent local tumor control.

Electric compound action potentials (ECAPs) and impedances in an open and closed operative site during cochlear implantation.

INTRODUCTION: In patients undergoing cochlear implantation, intraoperative measures of impedance and electrically evoked compound action potentials (ECAPs) are used to confirm device integrity and electrode array position. However, these electrophysiological parameters have been shown to decrease over time, with a small decrement observable as early as 24 h post implantation and becoming more apparent after 6 months. Whether the intraoperatively measured impedances and ECAPs recorded immediately after electrode insertion versus later in the operation or in an open versus closed operative site vary has not been documented. Such variation in measurement procedure may affect the ultimate operative outcome. PATIENTS AND METHODS: Between February and October 2016, 38 patients received a cochlear implant (Cochlear®), with half receiving a CI 522 device and the other half receiving a CI 512 device. These patients were distributed into three groups. In the first (group A; n = 21), the impedance and threshold neural response telemetry (tNRT) measures were taken before (M1) and after cutaneous suture (M2), whereas in the second group (group B; n = 11) they were taken twice in the open operative site, once at the time of electrode insertion (M1) and then again 10 min later (M2). The last group (group C; n = 6) was measured only once after a 10 min waiting time before closing the operative site. RESULTS: tNRTs of both group A and B were significantly higher at M1 than measured at M2. The magnitude of change in tNRT did vary significantly by group (P = .027) with group A having a bigger decrease than group B. For impedances there was evidence for a significant difference in M2 between the three groups (P = .012), with group C having significantly higher values compared to group A and B. CONCLUSION: Intraoperative tNRT measures change significantly over time, including within the first 10 min of implantation. One underlying etiology of this phenomenon for tNRTs seems to be the condition of the surgical site whereas changes of impedances can be best explained by the 'electrochemical cleaning' theory associated with the first stimulation of the electrode. However, for both impedances and tNRTs there also is an important impact of time as well as of acute perioperative changes in electrical conductivity.

[Newly developed biofeedback program for facial muscle training in patients with facial paralysis]. / Ein neu entwickeltes Biofeedbackprogramm zum Gesichtsmuskeltraining für Patienten mit Fazialisparese.

BACKGROUND: Patients with facial paralysis are significantly limited in their quality of life (QoL). If no irreversible nerve damage is apparent, intensive training of the facial muscles is recommended in addition to drug-based therapy with cortisone. In order to improve training, we have developed a digital biofeedback mirror with motion magnification to indirectly influence the vegetative nervous system. OBJECTIVE: The aim of this work was to evaluate the reliability of the biofeedback program compared to clinical examination and classification according to House-Brackmann. METHODS: Our biofeedback system is similar to a mirror with the additional advantage of increasing a patient's self-control. It not only reflects the patient's image, but also potentiates movement through video processing and a magnifying function. For this purpose, patient's facial movements are filmed and amplified in real-time. Thus, even the smallest movements can be made visible and measured so that patients receive feedback on nerve regeneration. This can increase patient's motivation for daily facial muscle training and improve compliance. RESULTS: In the present study, restriction of QoL was evaluated and objectivized with Facial Clinimetric Evaluation Scale (FaCE) and Facial Disability Index (FDI) questionnaires. It was demonstrated that the patients' self-perception was associated with poor QoL. CONCLUSION: In the current study, measurement of the facial movements showed a reliable agreement with the clinical classification according to House-Brackmann. The biofeedback system is a reliable support tool during the regeneration phase in patients with facial paralysis..

First use of a new retractor in transoral robotic surgery (TORS).

Transoral robotic surgery (TORS) has gained importance in head and neck surgery due to the possibility to visualize regions within the pharynx and larynx which are difficult to access. The success of transoral surgery depends on the exposure of the region of interest in order to allow visualization using a camera system. The Medrobotics Flex(®) Robotic System is a new flexible endoscopic system designed to overcome difficulties experienced in transoral surgery using other robotic systems with rigid endoscopes and instruments. In this article, we describe the first use of the Medrobotics Flex(®) Retractor in humans, a retractor designed for advanced transoral procedures. We report our experience in 11 patients requiring surgery of the oropharynx, hypopharynx, and supraglottic larynx. In all cases, we successfully exposed all targeted surgical regions. We experienced easy handling of the retractor alongside comparable positioning times and no observed mucosal damage.

[Advances in transoral robotic surgery]. / Fortschritte in der transoralen roboterassistierten Chirurgie.

BACKGROUND: The role of transoral robotic surgery (TORS) in the treatment of head and neck tumors has expanded in the last decade. OBJECTIVES: We present the development and current advances in TORS along with the current indications and contraindications, and describe future developments. METHODS: We present our own studies and review those in the literature. RESULTS: Since approval of the da Vinci® system, the number of TORS cases has increased significantly. The main indications are tumors of the oropharynx and supraglottis. Most published studies are retrospective case series with no control group. In addition to the further development of the da Vinci® system, the introduction of the Flex®-system is a significant progression. The costs of using robotic systems are high. CONCLUSIONS: Technical improvement of robotic systems and the development of new surgical techniques will further expand the indications for TORS. The value of TORS needs to be assessed in prospective controlled studies.